Health Care for Women International
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Health Workers’ Perceptions of Italian Female Adolescents: A Qualitative Study About Sexuality, Contraception, and Caring Practices in Family Health Centers Maria Giulia Olivari, Elena Santoro, Elisa Stagni Brenca, Emanuela Confalonieri & Paola Di Blasio To cite this article: Maria Giulia Olivari, Elena Santoro, Elisa Stagni Brenca, Emanuela Confalonieri & Paola Di Blasio (2015) Health Workers’ Perceptions of Italian Female Adolescents: A Qualitative Study About Sexuality, Contraception, and Caring Practices in Family Health Centers, Health Care for Women International, 36:11, 1239-1254, DOI: 10.1080/07399332.2015.1069295 To link to this article: http://dx.doi.org/10.1080/07399332.2015.1069295
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Date: 06 November 2015, At: 02:44
Health Care for Women International, 36:1239–1254, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2015.1069295
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Health Workers’ Perceptions of Italian Female Adolescents: A Qualitative Study About Sexuality, Contraception, and Caring Practices in Family Health Centers MARIA GIULIA OLIVARI, ELENA SANTORO, ELISA STAGNI BRENCA, EMANUELA CONFALONIERI, and PAOLA DI BLASIO Psychology Department, Universit`a Cattolica del Sacro Cuore; and CRIdee, Milan, Italy
Our aim was to explore health workers’ perceptions of providing sexuality and contraception care for female adolescents within family health centers. We interviewed 26 volunteer health workers and analyzed the interviews using thematic analysis. We identified three main themes: (a) “adolescents and sexuality,” with the subthemes “initiation rite,” “me like the others,” and “just for fun”; (b) “adolescents and contraception,” with the subthemes “omnipotent adolescents,” “aware adolescents,” and “women’s responsibility”; and (c) “health workers and adolescents,” with the subthemes “to put in order,” “to catch,” and “to teach to take care of themselves.” Our results provided an interesting picture of health workers’ perceptions of their work with Italian female adolescents regarding sexuality and contraception. In our article, we address an important issue that could be interesting for professionals worldwide who deal with sexual education, risky sexual behavior prevention, and adolescents’ sexual and contraceptive behavior. We examined this phenomenon through the lens of Italian health workers who usually care for female adolescents at family health centers. We employed a qualitative research method by conducting semistructured interviews with a voluntary sample of 26 Italian health workers, and we analyzed their reflections on their experiences of caring for these adolescents through thematic analysis. We believe that our study sheds new light on practice with female Received 6 March 2014; accepted 28 June 2015. Address correspondence to Maria Giulia Olivari, Psychology Department, Universit`a Cattolica del Sacro Cuore, Largo Gemelli 1, Milan 20123, Italy. E-mail: [email protected] 1239
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adolescent patients at family health centers. In particular, we believe that the knowledge gained from this study can help health professionals caring for teenagers to understand the unique needs of these patients, who seek support and sustained, lasting relationships in order to become able to care for themselves (Kirby, Laris, & Rolleri, 2007; Olivari, Confalonieri, & Ionio, 2011; Wahn, von Post, & Nissen, 2007). Adolescence is a period characterized by deep biological, social, and psychological changes (Adams & Berzonsky, 2008) that contribute to create the right environment for an increased interest in sexuality. Adolescent sexuality can be linked to both normative and risky developmental paths (Giannotta, Ciairano, Spruijt, & Spruijt-Metz, 2009; Mitchell & Wellings, 1998). In order to have safe and positive sexual experiences, adolescents should embrace the socioemotional and cognitive abilities needed to engage in sexual and romantic relationships that are characterized by affection and equality (Ciairano, Kliewer, Bonino, Miceli, & Jackson, 2006; Giannotta et al., 2009). Moreover, they should make responsible decisions regarding contraception by negotiating its usage with their partners in a context full of emotions (Beyth-Marom & Fischoff, 1997; Bonino, Cattelino, & Ciariano, 2007). These abilities may not always be fully developed among younger adolescents, putting them at risk for sexual risk taking. According to Eaton and colleagues (2008), sexual risk taking is a priority for public health because it can lead to several negative outcomes, such as sexually transmitted diseases and unwanted pregnancies. The World Health Organization (WHO) estimated that 499 million new cases of curable sexually transmitted infections (STIs) occur annually worldwide in adults aged 15–49 years (2008). Compared with adults, adolescents aged 15–19 and young adults aged 20–24 are at higher risk for acquiring STIs (Centers for Disease Control and Prevention, 2009). Regarding adolescent pregnancy, about 16 million girls aged 15–19 and two million girls under the age of 15 give birth every year (WHO, 2012). Although Italy has one of the lowest rates of adolescent pregnancies (7%) in Europe (Wellings & Parker, 2006), the country has reported a recent increase in teen pregnancies: young mothers under 20 years of age constitute approximately 1.77% of the Italian population (Baumgartner, Dhayanandhan, Laghi, & Riccio, 2011). Besides the growth of both sexually transmitted diseases and pregnancies among adolescents, another important phenomenon is the increased use of emergency contraception. According to Daniels, Jones, and Abma (2013), emergency contraceptives consumption has increased in the last several years in the United States of America: from 2006–2010, 11% (5.8 million) of sexually active women aged 15–44 used emergency contraception, compared with 4.2% of women in 2002. Moreover, almost 15% of those from 2006 to 2010 were adolescents. In Italy, there are no official laws regarding sexual education, nor are there any official data about the provision of sexuality education (Wellings & Parker, 2006). Sexual education programs are usually very limited in duration
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and vary widely regarding their content. Some of them take into account just the physical aspects of risk linked to sexuality, while others focus on both the emotional and relational aspects of adolescent romantic and sexual relationships. To get information about sexuality and contraception, Italian adolescents can apply to family health centers. These centers were established in Italy in 1975, according to Law No. 405, which instituted public structures to provide health care assistance to promote women and children’s health. These structures usually have a multidisciplinary team, comprising a general doctor, a gynecologist, a midwife, a nurse, a health care assistant, an educator, a social worker, and a psychologist. When women access a family health center for the first time, they are usually received for a talk, which is aimed at better understanding their needs and requests and to present the services provided by the family health center. This first contact is usually with the nurse, health care assistant, or educator, depending on the person who is in charge of this admission moment at each health center and on the presence of the health professionals on different days of the week. After this first contact and according to their needs, patients are sent to the various health professionals who work at the center. The health workers’ aims are to ensure psychological and social assistance to live parenthood in a responsible way and to sustain the couple and family when problems arise. Moreover, they provide counseling, prescribe contraceptive methods, disclose information in order to prevent or promote pregnancies, and support and sustain the mother and the baby during the pregnancy and the postpartum period. According to Law No. 194/1978, abortion is available to women for health, economic, social, or family reasons up to 90 days after conception (12 weeks). Between the twelfth week and twentieth week, abortion is only permitted if the pregnant woman’s life is threatened. Pregnant women who are considering terminating a pregnancy can refer, aside from primary physicians and public hospitals, to family health centers. Here, they can receive the necessary certification for the intervention, as well as counseling and support in the period following it. Minors can access family health centers without their parents’ authorization, and their privacy is completely guaranteed. Most family health centers have a specific day on which adolescents and young adults can access the center for psychological counseling, medical or gynecological visits, contraception, and emergency contraception prescription without making an appointment. Moreover, in the case of an undesired pregnancy, if minors do not want to involve their parents, they can access the family health center to obtain a report for a minor judge who will authorize the procedure. The literature suggests that there may be a relationship between providers’ perceptions and the care they provide their patients (Breheny & Stephens, 2007; Wahn et al., 2007). In particular, Breheny and Stephens (2007) analyzed health workers’ perceptions of adolescent mothers; their findings suggested that the latter were perceived as na¨ıve, distracted, selfcentered, and unable to be good mothers. Wahn and colleagues (2007)
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studied midwives reflections on pregnant adolescents and found that it is extremely important for midwives to take young mothers seriously, without condemning them for having a baby during adolescence, and to care for them in a professional way. Olivari and colleagues (2011) investigated midwives’ and psychologists’ perceptions of pregnant adolescents and found that their main feeling toward them was of concern and protection. All of these studies highlight the importance of health workers to be aware of their perceptions regarding their adolescent patients and how they can influence the health workers’ relationships with them. To our knowledge, no studies in Italy have investigated the perceptions of health workers on their work experience with adolescents with regard to sexuality and contraception. Health workers in the family health centers mainly work with female adolescents, because only a few males request help or support. In this study, we aim to explore health workers’ perceptions of caring for female adolescent patients regarding sexuality and contraception topics by analyzing their reflections on their experiences of caring for these girls within family health centers.
METHOD Participants Twenty-six volunteer health workers (eight midwives, five gynecologists, five nurses, three social workers, two psychologists, two health care assistants, and one educator) took part in this study. The participants were eligible if they took care of adolescent patients regarding sexuality and contraception topics in family health centers. The participants were mainly women (N = 24; 92.3%), with a mean age of 49.7 years (SD = 6.9). The health workers had a mean working experience of 24.7 years (SD = 9.7) and a mean working experience in family health centers of 12.6 years (SD = 10.3).
Procedure and Data Collection Trained researchers conducted semistructured interviews to gather information on the participants’ work experience with adolescents surrounding sexuality and contraception. The interview topic guide contained open questions about the adolescents’ motivations when they come to the family health center; their awareness of sexual and contraceptive behaviors; the contraceptive methods they use; and their use of emergency contraception. Moreover, they were asked about the adolescents’ peer influence in the choice to be sexually active and the presence of the partner in decisions regarding contraception. The researchers interviewed the participants in comfortable private rooms at family health centers. The interviews averaged around 45 minutes each; they were audio recorded and later transcribed verbatim.
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The recruitment of participants continued until saturation was reached and no new topics emerged in the interviews (Guest, Bunce, & Johnson, 2006). Permission to undertake this study was granted by the Ethics Committee of Universit`a Cattolica del Sacro Cuore. Before the beginning of the interview, all of the participants signed a written consent form explaining the study, definitions, the study’s objectives, and the rights of the participants taking part in the study.
Data Analysis The interview data were independently coded by three researchers using thematic analysis. Thematic analysis is the most widely used method in qualitative studies “for identifying, analyzing, and reporting patterns (themes) within data” (Braun & Clarke, 2006, p. 79). This method was used to identify health workers’ prominent perspectives on sexuality and contraception during adolescence and their practices to take care of adolescent patients. The researchers worked on achieving familiarity with the text, which is the first step suggested by Braun and Clarke (2006). All of the interview tapes were transcribed verbatim, and each researcher read and reread the transcripts to gain an initial understanding of the content. Coding was done manually by highlighting key words and phrases in the text (Braun & Clarke, 2006). Key words and text passages were independently categorized into themes and subthemes. Finally, a meeting was held to discuss the codes and identify and name the themes and their underlying subthemes until an agreement was reached. There were no significant differences among the authors about the salience of the identified themes. According to Braun and Clarke, “a theme captures something important about the data in relation to the research question, and represents some level of patterned response or meanings within the data set” (2006, p. 82).
RESULTS We identified three main themes: (a) “adolescents and sexuality,” with the subthemes “initiation rite,” “me like the others,” and “just for fun”; (b) “adolescents and contraception,” with the subthemes “omnipotent adolescents,” “aware adolescents,” and “women’s responsibility”; and (c) “health workers and adolescents,” with the subthemes “to put in order,” “to catch,” and “to teach to take care of themselves.” We described each theme and their subthemes using direct quotations from the interviews to better expose health workers’ perceptions. We translated the reported quotations from Italian into English, while trying to respect the original verbal expressions related to the discursive
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context in which they were elicited. A native English speaker performed the back translation to ensure that the authors captured the nuances intended in the original language.
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Adolescents and Sexuality The first theme gathered health workers’ perceptions on the ways in which female adolescents lived their sexuality, in particular, during their first sexual intercourse. According to the health workers, the first sexual intercourse accomplished different functions and fulfilled several needs regarding the adolescent’s growth path. Initiation rite. The health workers described the adolescent’s sexual debut as an attempt to be identified and recognized as an adult, above all within the peer group: It’s something like an initiation rite, so maybe they don’t feel adequate if they don’t start to be sexually active. (Gynecologist)
In particular, in the health workers’ experience, the assumption of hormonal contraception is a very important moment in the adolescents’ lives, because it marks the entry into the adult world: In my opinion, the first sexual intercourse and even the next step, that is the use of hormonal contraceptives, is really a sort of transition rite. (Social worker)
Moreover, according to health workers, the first sexual intercourse could be experienced as a duty that needs to be carried out in order to be part of the adult world. Frequently, this desire was stronger than a real affective and emotional motivation: Sometimes we perceive that everyone must have sexual intercourse; therefore, it’s quite like punching in. . . . It seems that sexual intercourse is an obligation, something that adolescents have to do. (Nurse)
Me like the others. In the health workers’ experience, adolescents’ decision to become sexually active was often a response to their need to be part of the peer group. The health workers identified the constant and typical adolescent need to compare themselves with their peers. In this way, being sexually active became a way to be accepted by friends and in tune with them:
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It’s almost a way to identify with a group, so we can say that to be fully part of the group, they also have to share this kind of experience. (Midwife)
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Furthermore, the health workers worried about the possibility that adolescents live their sexuality in an attempt to satisfy their partner’s demands. According to their experience, adolescents’ sexual debuts frequently occurred not because of a personal desire, but to maintain the relationship with the partner and avoid his refusal: We see that a lot of teenagers feel almost forced (to have first sexual intercourse), maybe for not to be less than the others or maybe—and in my opinion this is worrying–because above all they feel obliged to meet boyfriends’ needs. (Social worker)
Moreover, the health workers believed that sexually active girls could be more popular within the peer group. In their perception, sexuality became a way to gain a better position in the eyes of friends: Since everyone does it, I’ll do myself too so I can be part of the group and be better regarded, almost as a point accumulation. (Nurse)
Just for fun. According to the health workers, adolescents frequently lived sexually as a fun game. In their experience, the search for the ludic dimension of sexuality could lead adolescents to underestimate the risky behaviors that are connected to their health and well-being: Very often, it seems that adolescents have their first sexual intercourse just for fun: they understand the playful aspect, but they’re a little lacking in responsibility and awareness. Above all, they’re lacking risk-taking awareness, in particular regarding risk of possible pregnancies and sexually transmitted diseases. (Social worker)
Another motivation that is linked to this was the curiosity and desire for the adolescents to test their bodies’ sexual functions: Many adolescents experience (sexuality) to test it, out of curiosity. . . . They don’t do it with awareness of the facts. (Midwife)
Adolescents and Contraception This theme regarded the health workers’ perceptions of the ways adolescents used and negotiated contraception within the couple. The health workers
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described two types of adolescents who differed in their attitudes toward the use of contraception and suggested the presence of a negotiation dimension among adolescents regarding contraceptive methods. Omnipotent adolescents. In the health workers’ experience, adolescents could be led by omnipotence, challenge, and a lack of planning and responsibility in their contraceptive behaviors. These adolescents could believe that they were invulnerable and usually underestimated the negative consequences of unsafe sexual behavior: They engage in the event, without any precautions, and then they have to manage problems bigger than them. (Gynecologist) They have the ideas “it cannot happen to me” or “I’m too young, it cannot happen.” (Gynecologist)
Aware adolescents. Health workers believed that a great number of adolescents are able to live sexually in a conscious way, search for information about contraceptive methods, and request a prescription for hormonal contraception. This consciousness usually prevented these girls from coming to the family health centers to request emergency contraception: If they come with this request (for contraception), they show honor: they really show they have understood that sexual activity involves a certain risk, so they want to protect themselves from the risk, and this behavior shows that they’re aware. (Midwife)
Women’s responsibility. According to the health workers, girls were expected by their partner to be responsible for the relationship, particularly for taking care of the contraceptive methods and potential outcomes. There was a dimension of negotiation, however, among adolescent couples regarding contraception. In particular, the health workers underlined that adolescents talked about contraception and came together to the family health center more than adult couples usually did: More often, the girl takes charge of contraception, but even in my experience, adolescents talk about it more than adult couples. (Gynecologist) I noticed that the request often comes from the male partner, who asks his girlfriend to go to the family health center to use a safer contraceptive method. (Social worker)
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Health Workers and Adolescents
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This theme captures the health workers’ representations regarding the way they took care of their adolescent patients. To put in order. In the health workers’ experience, girls had lots of information and usually received it from several sources. In particular, they underlined that adolescents frequently used the Internet to make up their minds. The information they obtained in this way was not always correct, however, and health workers worried about this, believing that part of their mission consists of putting these false or uncorrected beliefs in order: Adolescents have a lot of information, and the Internet’s availability is powerful in this sense, but they’re often misinformed. Therefore, we need to give insights about the meaning and awareness of contraception as well as correct their knowledge. (Social worker)
Moreover, the health workers’ desire was to implement adolescents’ knowledge and to provide them useful information to live sexuality in a safer way: I have to say that misinformation is high and information is not always correct. ... Sometimes [their] knowledge is more fantasy than reality! Generally, we try to give useful information for an aware contraception choice. (Social worker)
To catch. In their practice with adolescent patients, health workers underlined the importance of trying to build a lasting relationship with their young patients, starting with contraception counseling: Obviously, after the morning-after pill prescription, if the adolescent is not a family health center patient yet, we try to establish a relationship with her, so that we can more responsibly deal with a contraception talk that could be preventive and not, once again, based on emergency. (Social worker)
This moment became an opportunity to become known as a service and to take care of patients’ health and well-being by providing clinical services and counseling about relationship, emotional, and social issues during the lifespan development: It’s also a way to get the person to approach the institution, not only from the contraception point of view, because usually we can become a source for other questions. (Gynecologist)
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To teach them to take care of themselves. According to the health workers, their main task was to empower adolescents regarding general sexuality and health to actively involve them in gaining consciousness about healthy behaviors: It’s also important that an institution like a family health center manage these situations, because here adolescents find an individual welcome, an accurate deepening of their knowledge, and resulting prevention work; therefore, we can also offer an occasion to build a better prevention and empowerment relationship. (Social worker)
The health workers aimed at leading these patients to be protagonists in taking care of themselves and not merely passive receptors of information: The family health center wants to offer a counseling approach after this thing (contraceptive prescription) to transform this event into something with an educational and formational value: we don’t want to accuse but to teach them to take care of themselves. (Psychologist)
DISCUSSION This study provides a unique description of Italian health workers’ perceptions of taking care of adolescent patients regarding sexuality and contraception topics. Health workers identified several functions linked to adolescent sexuality, and their perceptions were consistent with previous research focusing on adolescents’ descriptions of meanings of sexual intercourse (Bonino et al., 2007; Diamond & Savin-Williams, 2011; Giannotta et al., 2009; SavinWilliams & Diamond, 2004). In particular, the health workers described three main needs connected to sexual debuts. The first one was the desire to access the adult world to become emancipated from childhood. The researchers highlighted that a typical process during adolescent growth is gaining an adult status by acting out sexual behaviors considered typical of adulthood (Bonino et al., 2007; Diamond & Savin-Williams, 2011; Savin-Williams & Diamond, 2004). According to the health workers, adolescents desire to prove to themselves, to their friends, and to adults through transitioning from childhood, hoping to obtain a more adult status. This need, however, may be linked to a precocious sexual debut that might lead early adolescents to engage in sexual risk taking. Moreover, the health workers expressed their concern for adolescents who lived sexuality not to fulfil their own needs, but to respond to their partners’ needs. Their concern is supported by previous research underlining that a necessary condition for positively experiencing sexuality is the ability
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to have relationships characterized by the recognition of equality, without being forced (Beyth-Marom & Fischhoff, 1997; Bonino et al., 2007). The second function identified by health workers was the adolescent need to become sexually active in an attempt to belong to the peer group. The researchers revealed that peer emulation is a typical step in adolescent development. The desire to be sustained by peers during this period of life is strong and guides several behaviors (Dijkstra & Veenstra, 2011), including sexual ones (Bonino et al., 2007). The third motivation identified by the health workers regarding adolescent sexuality was the desire to have fun and satisfy a sense of curiosity. The search for and exploration of new sensations, as well as the desire to test their own limits and capabilities, are typical adolescent attitudes (Bonino et al., 2007; Haydon, McRee, & Halpern, 2011). Moreover, Savin-Williams and Diamond (2004) and Diamond and Savin-Williams (2011) maintained that curiosity frequently guides adolescents when experimenting sexually. Two different typologies of adolescents who use completely different contraceptive methods emerged from the health workers’ descriptions. The first type comprised adolescents who perceived themselves as omnipotent and invulnerable. According to the health workers, these adolescents had false beliefs regarding themselves and their health issues. In particular, omnipotent adolescents frequently did not use efficient contraceptive methods and avoided protecting themselves from the negative consequences of risky sexual behavior. Several authors found a connection between the adolescent’s belief in being omnipotent and invulnerable and higher risks of precocious pregnancy (Durant & Sanders, 1989) and contracting HIV (Cicognani & Zani, 1999), as well as the presence of several sexual partners (Greene, Rubin, Hale, & Walters, 1996; Serovich & Greene, 1997). In addition to omnipotent adolescents, health workers identified a completely different category of young patients. These girls worried about their health and came to the family health center looking for contraceptive counseling. These adolescents showed an awareness of the risks connected to sexual behavior and were conscious about the possible negative consequences of unsafe sexual behavior. Finally, the health workers underlined the importance of the emerging dimension of negotiation regarding contraceptive methods within the adolescent couple. According to the health workers, young couples discussed and communicated about contraception. Focusing on contraceptive negotiations, the researchers underlined the relationship between discussing this topic and the probability of using contraceptives (Kirby et al., 2007; Manlove, Ryan, & Franzetta, 2004). Finally, we included and interviewed health workers from different disciplines who met and interacted with these young patients at different moments and for different reasons. From our study, however, it emerged that in their practice with adolescents, all of them addressed their work by sharing
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the same representation of taking care, which takes place at three different levels. The first one is linked to a need for revising the information possessed by adolescents, correcting the wrong ideas, and putting them in order. In their experience, adolescents were not completely uninformed on sexual topics, but their knowledge needed supervision and improvement. Above all, they felt that adolescents mainly asked their peer group for advice and searched for help on the Internet, thus taking the chance of not finding adequate answers to their questions. The health workers are led by this concern in their practice: teenagers were perceived as badly equipped to safely deal with this developmental challenge. The health workers’ desires were therefore to put the adolescents’ information in order, dispel the false myths circulating among the youngest, correct the incorrect information, and teach the correct information. These concerns are supported by the findings of the Societ`a Italiana di Pediatria report (2012) highlighting that more than half of the interviewed adolescents believed in having all useful information about sexuality and contraceptive methods, and that their chosen information sources are friends and schoolmates. Second, the health workers expressed their desire to build a stable and lasting relationship with their young patients, starting from contraceptive counseling. The health workers hoped that adolescents looking for advice regarding contraception would have a long-term relationship with health workers, in the hopes of becoming a reference point for adolescents, so that they could ask for help in different times of their lives. The importance of creating a stable relationship with adolescents has already been highlighted in the literature. In their research focusing on midwives’ work with adolescent mothers, Wahn and colleagues (2007) identified the creation of trusting and long-term relationships with adolescents as a priority to sustain and support adolescents across the difficult challenges linked to motherhood. Third, at a higher level, the health workers were willing to make adolescents aware and autonomous in their decision-making processes concerning sexuality in particular and health in general. This desire to lead adolescents to become the protagonists of their lifestyle choices is linked to an educational mission that sees its ultimate goal in passing on the tools and equipment necessary to meet life’s challenges in a healthy and safe way. In addition to the necessity of providing adolescents with correct and complete information regarding contraception and sexuality, there is, in fact, the need to increase and promote these skills (critical thinking, decision making, and problem solving) in adolescents that could act as protective factors in their future lives. Researchers investigating the characteristic that sexual education interventions should have in order to be efficient (Federazione Italiana di Sessuologia Scientifica, 2011; Kirby, 2001, 2002; Kirby et al., 2007) underline the importance of engaging adolescents through an active methodology, using activities like role-playing, written exercises, and group discussion. All of these techniques aim at stimulating a profound reflection regarding
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sexuality, and this aspect seems to be the final aim of Italian health workers in taking care of their young patients.
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CONCLUSION When considering the implications of the findings, it is important to underline that this study was carried out with a limited number of health workers from a limited geographic region in Italy. Our findings cannot be generalized, therefore, although they can contribute to an area in health worker practice that has not been deeply investigated in earlier research. Moreover, the health workers taking part in the research were voluntarily recruited, and they had varying degrees of experience in caring for adolescents. Despite the limitations of the study, the following findings are relevant for the care of adolescents. In our opinion, several important aspects of working with adolescents emerged from this study, and the most important appeared to be linked to the specific characteristics of taking care of adolescents regarding sexuality and contraception issues. From our interviews, strong concerns regarding adolescent misinformation on sexual topics emerged, which led the way in caring for adolescents. The health workers emphasized the desire to engage and build lasting relationships with their young patients, aiming to be a positive reference point in their lives. Moreover, they proposed sustaining adolescents in this phase of life by promoting an aware and conscious attitude toward sexuality and contraception. In this way, health workers focused their practice not only on preventing sexual risk taking but also on promoting skills that can lead adolescents to be main protagonists in the choices that affect their lives and to be autonomous in taking care of themselves. We believe that working on preventing sexual risk taking will contribute to reductions in sexually transmitted diseases, undesired pregnancies, and abortion requests, which are all stressful life events for most women, regardless of their age. Moreover, we believe that also focusing on the promotion of adolescents’ personal life skills will be very useful in later life stages; during the transition from adolescence to adulthood, these skills could in fact bring about a safer and more positive management of romantic and sexual relations. Adolescents who are able to recognize their emotions and those of others, answer them in a responsive way, make healthy decisions, and solve problems will become, with greater probability, responsible adults who will respect their romantic and sexual partners. We believe that a longterm effect of implementing these abilities could also include decreases in stalking and dating violence, which are becoming more frequent among adolescents (Connolly et al., 2010; Williams, Connolly, Pepler, Craig, & Laporte, 2008).
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We perceived these health workers as being prepared and able to identify the specificities and different needs of their young patients by trying to answer them in a careful way. In our opinion, Italian health workers are guided in their work by a sense of concern for these adolescents, who are not always perceived as mature enough to face sexuality, but also by a desire to support them in their growth process and allow them to become responsible and healthy adults. We believe that health workers should be aware of their perceptions regard these young patients, because the ways in which these patients are perceived could influence the care relationship. In future research, it could be interesting to identify the adolescents’ beliefs and attitudes toward sexuality and contraception, and compare them with those of the health workers. Moreover, it could be relevant to investigate adolescents’ needs or desires to be taken care of by adults or professionals on these topics.
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Daniels, K., Jones, J., & Abma, J. (2013). Use of emergency contraception among women aged 15–44: United States, 2006–2010. NCHS data brief, no 112. Hyattsville, MD: National Center for Health Statistics. Diamond, L. M., & Savin-Williams, R. C. (2011). Sexuality. In B. Brown & M. Prinstein (Eds.), Encyclopedia of adolescence (pp. 314–321). New York, NY: Academic Press. Dijkstra, J. K., & Veenstra, R. (2011). Peer relations. In B. B. Brown & M. Prinstein (Eds.), Encyclopedia of adolescence (pp. 255–259). New York, NY: Academic Press. Durant, R. H., & Sanders, J. M. (1989). Sexual behavior and contraceptive risk taking among sexually active adolescent females. Journal of Adolescent Health Care, 10, 1–9. Eaton, D. K., Kann, L., Kinchen, S., Shanklin, S., Ross, J., Hawkins, J., . . . Wechsler, H. (2008). Youth risk behavior surveillance—United States, 2007. Morbidity and mortality weekly report. Surveillance Summaries, 57, 1–131. Federazione Italiana di Sessuologia Scientifica. (2011). Standard per l’Educazione Sessuale in Europa [Standard for sexual education in Europe]. Retrieved from http://www.fissonline.it/articoli/documenti.html Giannotta, F., Ciairano, S., Spruijt, R., & Spruijt-Metz, D. (2009). Meanings of sexual intercourse for Italian adolescents. Journal of Adolescence, 32, 157–169. Greene, K., Rubin, D. L., Hale, J. L., & Walters, L. H. (1996). The utility of understanding adolescent egocentrism in designing health promotion messages. Health Communication, 8, 131–152. Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough? An experiment with data saturation and variability. Field Methods, 18(1), 59–82. Haydon, A. A., McRee, A. L., & Halpern, C. T. (2011). Unwanted sex among young adults in the U.S.: The role of physical disability and cognitive performance. Journal of Interpersonal Violence, 26, 3476–3493. Kirby, D. (2001). Emerging answers: Research findings on programs to reduce teen pregnancy. Washington, DC: National Campaign to Prevent Teen Pregnancy. Kirby D. (2002). Effective approaches to reducing adolescent unprotected sex, pregnancy, and childbearing. The Journal of Sex Research, 39, 51–57. Kirby, D., Laris, B. A., & Rolleri, L. A. (2007). Sex and HIV education programs: Their impact on sexual behaviors of young people throughout the world. Journal of Adolescent Health, 40, 206–217. Manlove, J., Ryan, S., & Franzetta, K. (2004). Contraceptive use and consistency in U.S. teenagers most recent sexual relationships. Perspectives on Sexual and Reproductive Health, 36, 265–275. Mitchell, K., & Wellings, K. (1998). Risks associated with early sexual activity. In J. Coleman & D. Roker (Eds.), Teenage sexuality (pp. 81–100). Amsterdam, The Netherlands: Harwood Academic Publishers. Olivari, M. G., Confalonieri, E., & Ionio, C. (2011). Italian psychologists’ and midwives’ perceptions of the pregnant teen: A qualitative study. Journal of Reproductive and Infant Psychology, 29, 343–353. Savin-Williams, R. C., & Diamond, L. M. (2004). Sex. In R. M. Lerner & L. Steinberg (Eds.), Handbook of adolescent psychology (2nd ed., pp. 189–231). New York, NY: John Wiley & Sons.
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Serovich, J. M., & Greene, K. (1997). Predictors of adolescent sexual risk taking behaviors which put them at risk of contracting HIV. Journal of Youth and Adolescence, 26, 429–444. Societ`a Italiana di Pediatria. (2012). Abitudini e stili di vita degli adolescenti italiani, Indagine Annuale [Habits and life styles of Italian adolescents, annual survey]. Retrieved from http://sip.it/wp-content/uploads/2010/ 05/Indagine-Adolescenti-2011-2012.pdf Wahn, E. H., von Post, I., & Nissen, E. (2007). A description of Swedish midwives’ reflections on their experience of caring for teenage girls during pregnancy and childbirth. Midwifery, 23, 269–728. Wellings, K., & Parker, R. (2006). Sexuality education in Europe: A reference guide to policies and practices, The SAFE Project. London, UK: London School of Hygiene and Tropical Medicine. Williams, T. S., Connolly, J., Pepler, D., Craig, W., & Laporte, L. (2008). Risk models of dating aggression across different adolescent relationships: A developmental psychopathology approach. Journal of Consulting and Clinical Psychology, 76, 622. World Health Organization (WHO). (2008). Sexually transmitted infections, fact sheet no. 110. Retrieved from http://www.who.int/mediacentre/factsheets/fs110/en World Health Organization (WHO). (2012). Adolescent pregnancy, fact sheet no. 364. Retrieved from http://www.who.int/mediacentre/factsheets/fs364/en
ISSN: 0739-9332 (Print) 1096-4665 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcw20
Health Workers’ Perceptions of Italian Female Adolescents: A Qualitative Study About Sexuality, Contraception, and Caring Practices in Family Health Centers Maria Giulia Olivari, Elena Santoro, Elisa Stagni Brenca, Emanuela Confalonieri & Paola Di Blasio To cite this article: Maria Giulia Olivari, Elena Santoro, Elisa Stagni Brenca, Emanuela Confalonieri & Paola Di Blasio (2015) Health Workers’ Perceptions of Italian Female Adolescents: A Qualitative Study About Sexuality, Contraception, and Caring Practices in Family Health Centers, Health Care for Women International, 36:11, 1239-1254, DOI: 10.1080/07399332.2015.1069295 To link to this article: http://dx.doi.org/10.1080/07399332.2015.1069295
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Health Care for Women International, 36:1239–1254, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2015.1069295
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Health Workers’ Perceptions of Italian Female Adolescents: A Qualitative Study About Sexuality, Contraception, and Caring Practices in Family Health Centers MARIA GIULIA OLIVARI, ELENA SANTORO, ELISA STAGNI BRENCA, EMANUELA CONFALONIERI, and PAOLA DI BLASIO Psychology Department, Universit`a Cattolica del Sacro Cuore; and CRIdee, Milan, Italy
Our aim was to explore health workers’ perceptions of providing sexuality and contraception care for female adolescents within family health centers. We interviewed 26 volunteer health workers and analyzed the interviews using thematic analysis. We identified three main themes: (a) “adolescents and sexuality,” with the subthemes “initiation rite,” “me like the others,” and “just for fun”; (b) “adolescents and contraception,” with the subthemes “omnipotent adolescents,” “aware adolescents,” and “women’s responsibility”; and (c) “health workers and adolescents,” with the subthemes “to put in order,” “to catch,” and “to teach to take care of themselves.” Our results provided an interesting picture of health workers’ perceptions of their work with Italian female adolescents regarding sexuality and contraception. In our article, we address an important issue that could be interesting for professionals worldwide who deal with sexual education, risky sexual behavior prevention, and adolescents’ sexual and contraceptive behavior. We examined this phenomenon through the lens of Italian health workers who usually care for female adolescents at family health centers. We employed a qualitative research method by conducting semistructured interviews with a voluntary sample of 26 Italian health workers, and we analyzed their reflections on their experiences of caring for these adolescents through thematic analysis. We believe that our study sheds new light on practice with female Received 6 March 2014; accepted 28 June 2015. Address correspondence to Maria Giulia Olivari, Psychology Department, Universit`a Cattolica del Sacro Cuore, Largo Gemelli 1, Milan 20123, Italy. E-mail: [email protected] 1239
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adolescent patients at family health centers. In particular, we believe that the knowledge gained from this study can help health professionals caring for teenagers to understand the unique needs of these patients, who seek support and sustained, lasting relationships in order to become able to care for themselves (Kirby, Laris, & Rolleri, 2007; Olivari, Confalonieri, & Ionio, 2011; Wahn, von Post, & Nissen, 2007). Adolescence is a period characterized by deep biological, social, and psychological changes (Adams & Berzonsky, 2008) that contribute to create the right environment for an increased interest in sexuality. Adolescent sexuality can be linked to both normative and risky developmental paths (Giannotta, Ciairano, Spruijt, & Spruijt-Metz, 2009; Mitchell & Wellings, 1998). In order to have safe and positive sexual experiences, adolescents should embrace the socioemotional and cognitive abilities needed to engage in sexual and romantic relationships that are characterized by affection and equality (Ciairano, Kliewer, Bonino, Miceli, & Jackson, 2006; Giannotta et al., 2009). Moreover, they should make responsible decisions regarding contraception by negotiating its usage with their partners in a context full of emotions (Beyth-Marom & Fischoff, 1997; Bonino, Cattelino, & Ciariano, 2007). These abilities may not always be fully developed among younger adolescents, putting them at risk for sexual risk taking. According to Eaton and colleagues (2008), sexual risk taking is a priority for public health because it can lead to several negative outcomes, such as sexually transmitted diseases and unwanted pregnancies. The World Health Organization (WHO) estimated that 499 million new cases of curable sexually transmitted infections (STIs) occur annually worldwide in adults aged 15–49 years (2008). Compared with adults, adolescents aged 15–19 and young adults aged 20–24 are at higher risk for acquiring STIs (Centers for Disease Control and Prevention, 2009). Regarding adolescent pregnancy, about 16 million girls aged 15–19 and two million girls under the age of 15 give birth every year (WHO, 2012). Although Italy has one of the lowest rates of adolescent pregnancies (7%) in Europe (Wellings & Parker, 2006), the country has reported a recent increase in teen pregnancies: young mothers under 20 years of age constitute approximately 1.77% of the Italian population (Baumgartner, Dhayanandhan, Laghi, & Riccio, 2011). Besides the growth of both sexually transmitted diseases and pregnancies among adolescents, another important phenomenon is the increased use of emergency contraception. According to Daniels, Jones, and Abma (2013), emergency contraceptives consumption has increased in the last several years in the United States of America: from 2006–2010, 11% (5.8 million) of sexually active women aged 15–44 used emergency contraception, compared with 4.2% of women in 2002. Moreover, almost 15% of those from 2006 to 2010 were adolescents. In Italy, there are no official laws regarding sexual education, nor are there any official data about the provision of sexuality education (Wellings & Parker, 2006). Sexual education programs are usually very limited in duration
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and vary widely regarding their content. Some of them take into account just the physical aspects of risk linked to sexuality, while others focus on both the emotional and relational aspects of adolescent romantic and sexual relationships. To get information about sexuality and contraception, Italian adolescents can apply to family health centers. These centers were established in Italy in 1975, according to Law No. 405, which instituted public structures to provide health care assistance to promote women and children’s health. These structures usually have a multidisciplinary team, comprising a general doctor, a gynecologist, a midwife, a nurse, a health care assistant, an educator, a social worker, and a psychologist. When women access a family health center for the first time, they are usually received for a talk, which is aimed at better understanding their needs and requests and to present the services provided by the family health center. This first contact is usually with the nurse, health care assistant, or educator, depending on the person who is in charge of this admission moment at each health center and on the presence of the health professionals on different days of the week. After this first contact and according to their needs, patients are sent to the various health professionals who work at the center. The health workers’ aims are to ensure psychological and social assistance to live parenthood in a responsible way and to sustain the couple and family when problems arise. Moreover, they provide counseling, prescribe contraceptive methods, disclose information in order to prevent or promote pregnancies, and support and sustain the mother and the baby during the pregnancy and the postpartum period. According to Law No. 194/1978, abortion is available to women for health, economic, social, or family reasons up to 90 days after conception (12 weeks). Between the twelfth week and twentieth week, abortion is only permitted if the pregnant woman’s life is threatened. Pregnant women who are considering terminating a pregnancy can refer, aside from primary physicians and public hospitals, to family health centers. Here, they can receive the necessary certification for the intervention, as well as counseling and support in the period following it. Minors can access family health centers without their parents’ authorization, and their privacy is completely guaranteed. Most family health centers have a specific day on which adolescents and young adults can access the center for psychological counseling, medical or gynecological visits, contraception, and emergency contraception prescription without making an appointment. Moreover, in the case of an undesired pregnancy, if minors do not want to involve their parents, they can access the family health center to obtain a report for a minor judge who will authorize the procedure. The literature suggests that there may be a relationship between providers’ perceptions and the care they provide their patients (Breheny & Stephens, 2007; Wahn et al., 2007). In particular, Breheny and Stephens (2007) analyzed health workers’ perceptions of adolescent mothers; their findings suggested that the latter were perceived as na¨ıve, distracted, selfcentered, and unable to be good mothers. Wahn and colleagues (2007)
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studied midwives reflections on pregnant adolescents and found that it is extremely important for midwives to take young mothers seriously, without condemning them for having a baby during adolescence, and to care for them in a professional way. Olivari and colleagues (2011) investigated midwives’ and psychologists’ perceptions of pregnant adolescents and found that their main feeling toward them was of concern and protection. All of these studies highlight the importance of health workers to be aware of their perceptions regarding their adolescent patients and how they can influence the health workers’ relationships with them. To our knowledge, no studies in Italy have investigated the perceptions of health workers on their work experience with adolescents with regard to sexuality and contraception. Health workers in the family health centers mainly work with female adolescents, because only a few males request help or support. In this study, we aim to explore health workers’ perceptions of caring for female adolescent patients regarding sexuality and contraception topics by analyzing their reflections on their experiences of caring for these girls within family health centers.
METHOD Participants Twenty-six volunteer health workers (eight midwives, five gynecologists, five nurses, three social workers, two psychologists, two health care assistants, and one educator) took part in this study. The participants were eligible if they took care of adolescent patients regarding sexuality and contraception topics in family health centers. The participants were mainly women (N = 24; 92.3%), with a mean age of 49.7 years (SD = 6.9). The health workers had a mean working experience of 24.7 years (SD = 9.7) and a mean working experience in family health centers of 12.6 years (SD = 10.3).
Procedure and Data Collection Trained researchers conducted semistructured interviews to gather information on the participants’ work experience with adolescents surrounding sexuality and contraception. The interview topic guide contained open questions about the adolescents’ motivations when they come to the family health center; their awareness of sexual and contraceptive behaviors; the contraceptive methods they use; and their use of emergency contraception. Moreover, they were asked about the adolescents’ peer influence in the choice to be sexually active and the presence of the partner in decisions regarding contraception. The researchers interviewed the participants in comfortable private rooms at family health centers. The interviews averaged around 45 minutes each; they were audio recorded and later transcribed verbatim.
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The recruitment of participants continued until saturation was reached and no new topics emerged in the interviews (Guest, Bunce, & Johnson, 2006). Permission to undertake this study was granted by the Ethics Committee of Universit`a Cattolica del Sacro Cuore. Before the beginning of the interview, all of the participants signed a written consent form explaining the study, definitions, the study’s objectives, and the rights of the participants taking part in the study.
Data Analysis The interview data were independently coded by three researchers using thematic analysis. Thematic analysis is the most widely used method in qualitative studies “for identifying, analyzing, and reporting patterns (themes) within data” (Braun & Clarke, 2006, p. 79). This method was used to identify health workers’ prominent perspectives on sexuality and contraception during adolescence and their practices to take care of adolescent patients. The researchers worked on achieving familiarity with the text, which is the first step suggested by Braun and Clarke (2006). All of the interview tapes were transcribed verbatim, and each researcher read and reread the transcripts to gain an initial understanding of the content. Coding was done manually by highlighting key words and phrases in the text (Braun & Clarke, 2006). Key words and text passages were independently categorized into themes and subthemes. Finally, a meeting was held to discuss the codes and identify and name the themes and their underlying subthemes until an agreement was reached. There were no significant differences among the authors about the salience of the identified themes. According to Braun and Clarke, “a theme captures something important about the data in relation to the research question, and represents some level of patterned response or meanings within the data set” (2006, p. 82).
RESULTS We identified three main themes: (a) “adolescents and sexuality,” with the subthemes “initiation rite,” “me like the others,” and “just for fun”; (b) “adolescents and contraception,” with the subthemes “omnipotent adolescents,” “aware adolescents,” and “women’s responsibility”; and (c) “health workers and adolescents,” with the subthemes “to put in order,” “to catch,” and “to teach to take care of themselves.” We described each theme and their subthemes using direct quotations from the interviews to better expose health workers’ perceptions. We translated the reported quotations from Italian into English, while trying to respect the original verbal expressions related to the discursive
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context in which they were elicited. A native English speaker performed the back translation to ensure that the authors captured the nuances intended in the original language.
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Adolescents and Sexuality The first theme gathered health workers’ perceptions on the ways in which female adolescents lived their sexuality, in particular, during their first sexual intercourse. According to the health workers, the first sexual intercourse accomplished different functions and fulfilled several needs regarding the adolescent’s growth path. Initiation rite. The health workers described the adolescent’s sexual debut as an attempt to be identified and recognized as an adult, above all within the peer group: It’s something like an initiation rite, so maybe they don’t feel adequate if they don’t start to be sexually active. (Gynecologist)
In particular, in the health workers’ experience, the assumption of hormonal contraception is a very important moment in the adolescents’ lives, because it marks the entry into the adult world: In my opinion, the first sexual intercourse and even the next step, that is the use of hormonal contraceptives, is really a sort of transition rite. (Social worker)
Moreover, according to health workers, the first sexual intercourse could be experienced as a duty that needs to be carried out in order to be part of the adult world. Frequently, this desire was stronger than a real affective and emotional motivation: Sometimes we perceive that everyone must have sexual intercourse; therefore, it’s quite like punching in. . . . It seems that sexual intercourse is an obligation, something that adolescents have to do. (Nurse)
Me like the others. In the health workers’ experience, adolescents’ decision to become sexually active was often a response to their need to be part of the peer group. The health workers identified the constant and typical adolescent need to compare themselves with their peers. In this way, being sexually active became a way to be accepted by friends and in tune with them:
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It’s almost a way to identify with a group, so we can say that to be fully part of the group, they also have to share this kind of experience. (Midwife)
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Furthermore, the health workers worried about the possibility that adolescents live their sexuality in an attempt to satisfy their partner’s demands. According to their experience, adolescents’ sexual debuts frequently occurred not because of a personal desire, but to maintain the relationship with the partner and avoid his refusal: We see that a lot of teenagers feel almost forced (to have first sexual intercourse), maybe for not to be less than the others or maybe—and in my opinion this is worrying–because above all they feel obliged to meet boyfriends’ needs. (Social worker)
Moreover, the health workers believed that sexually active girls could be more popular within the peer group. In their perception, sexuality became a way to gain a better position in the eyes of friends: Since everyone does it, I’ll do myself too so I can be part of the group and be better regarded, almost as a point accumulation. (Nurse)
Just for fun. According to the health workers, adolescents frequently lived sexually as a fun game. In their experience, the search for the ludic dimension of sexuality could lead adolescents to underestimate the risky behaviors that are connected to their health and well-being: Very often, it seems that adolescents have their first sexual intercourse just for fun: they understand the playful aspect, but they’re a little lacking in responsibility and awareness. Above all, they’re lacking risk-taking awareness, in particular regarding risk of possible pregnancies and sexually transmitted diseases. (Social worker)
Another motivation that is linked to this was the curiosity and desire for the adolescents to test their bodies’ sexual functions: Many adolescents experience (sexuality) to test it, out of curiosity. . . . They don’t do it with awareness of the facts. (Midwife)
Adolescents and Contraception This theme regarded the health workers’ perceptions of the ways adolescents used and negotiated contraception within the couple. The health workers
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described two types of adolescents who differed in their attitudes toward the use of contraception and suggested the presence of a negotiation dimension among adolescents regarding contraceptive methods. Omnipotent adolescents. In the health workers’ experience, adolescents could be led by omnipotence, challenge, and a lack of planning and responsibility in their contraceptive behaviors. These adolescents could believe that they were invulnerable and usually underestimated the negative consequences of unsafe sexual behavior: They engage in the event, without any precautions, and then they have to manage problems bigger than them. (Gynecologist) They have the ideas “it cannot happen to me” or “I’m too young, it cannot happen.” (Gynecologist)
Aware adolescents. Health workers believed that a great number of adolescents are able to live sexually in a conscious way, search for information about contraceptive methods, and request a prescription for hormonal contraception. This consciousness usually prevented these girls from coming to the family health centers to request emergency contraception: If they come with this request (for contraception), they show honor: they really show they have understood that sexual activity involves a certain risk, so they want to protect themselves from the risk, and this behavior shows that they’re aware. (Midwife)
Women’s responsibility. According to the health workers, girls were expected by their partner to be responsible for the relationship, particularly for taking care of the contraceptive methods and potential outcomes. There was a dimension of negotiation, however, among adolescent couples regarding contraception. In particular, the health workers underlined that adolescents talked about contraception and came together to the family health center more than adult couples usually did: More often, the girl takes charge of contraception, but even in my experience, adolescents talk about it more than adult couples. (Gynecologist) I noticed that the request often comes from the male partner, who asks his girlfriend to go to the family health center to use a safer contraceptive method. (Social worker)
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Health Workers and Adolescents
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This theme captures the health workers’ representations regarding the way they took care of their adolescent patients. To put in order. In the health workers’ experience, girls had lots of information and usually received it from several sources. In particular, they underlined that adolescents frequently used the Internet to make up their minds. The information they obtained in this way was not always correct, however, and health workers worried about this, believing that part of their mission consists of putting these false or uncorrected beliefs in order: Adolescents have a lot of information, and the Internet’s availability is powerful in this sense, but they’re often misinformed. Therefore, we need to give insights about the meaning and awareness of contraception as well as correct their knowledge. (Social worker)
Moreover, the health workers’ desire was to implement adolescents’ knowledge and to provide them useful information to live sexuality in a safer way: I have to say that misinformation is high and information is not always correct. ... Sometimes [their] knowledge is more fantasy than reality! Generally, we try to give useful information for an aware contraception choice. (Social worker)
To catch. In their practice with adolescent patients, health workers underlined the importance of trying to build a lasting relationship with their young patients, starting with contraception counseling: Obviously, after the morning-after pill prescription, if the adolescent is not a family health center patient yet, we try to establish a relationship with her, so that we can more responsibly deal with a contraception talk that could be preventive and not, once again, based on emergency. (Social worker)
This moment became an opportunity to become known as a service and to take care of patients’ health and well-being by providing clinical services and counseling about relationship, emotional, and social issues during the lifespan development: It’s also a way to get the person to approach the institution, not only from the contraception point of view, because usually we can become a source for other questions. (Gynecologist)
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To teach them to take care of themselves. According to the health workers, their main task was to empower adolescents regarding general sexuality and health to actively involve them in gaining consciousness about healthy behaviors: It’s also important that an institution like a family health center manage these situations, because here adolescents find an individual welcome, an accurate deepening of their knowledge, and resulting prevention work; therefore, we can also offer an occasion to build a better prevention and empowerment relationship. (Social worker)
The health workers aimed at leading these patients to be protagonists in taking care of themselves and not merely passive receptors of information: The family health center wants to offer a counseling approach after this thing (contraceptive prescription) to transform this event into something with an educational and formational value: we don’t want to accuse but to teach them to take care of themselves. (Psychologist)
DISCUSSION This study provides a unique description of Italian health workers’ perceptions of taking care of adolescent patients regarding sexuality and contraception topics. Health workers identified several functions linked to adolescent sexuality, and their perceptions were consistent with previous research focusing on adolescents’ descriptions of meanings of sexual intercourse (Bonino et al., 2007; Diamond & Savin-Williams, 2011; Giannotta et al., 2009; SavinWilliams & Diamond, 2004). In particular, the health workers described three main needs connected to sexual debuts. The first one was the desire to access the adult world to become emancipated from childhood. The researchers highlighted that a typical process during adolescent growth is gaining an adult status by acting out sexual behaviors considered typical of adulthood (Bonino et al., 2007; Diamond & Savin-Williams, 2011; Savin-Williams & Diamond, 2004). According to the health workers, adolescents desire to prove to themselves, to their friends, and to adults through transitioning from childhood, hoping to obtain a more adult status. This need, however, may be linked to a precocious sexual debut that might lead early adolescents to engage in sexual risk taking. Moreover, the health workers expressed their concern for adolescents who lived sexuality not to fulfil their own needs, but to respond to their partners’ needs. Their concern is supported by previous research underlining that a necessary condition for positively experiencing sexuality is the ability
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to have relationships characterized by the recognition of equality, without being forced (Beyth-Marom & Fischhoff, 1997; Bonino et al., 2007). The second function identified by health workers was the adolescent need to become sexually active in an attempt to belong to the peer group. The researchers revealed that peer emulation is a typical step in adolescent development. The desire to be sustained by peers during this period of life is strong and guides several behaviors (Dijkstra & Veenstra, 2011), including sexual ones (Bonino et al., 2007). The third motivation identified by the health workers regarding adolescent sexuality was the desire to have fun and satisfy a sense of curiosity. The search for and exploration of new sensations, as well as the desire to test their own limits and capabilities, are typical adolescent attitudes (Bonino et al., 2007; Haydon, McRee, & Halpern, 2011). Moreover, Savin-Williams and Diamond (2004) and Diamond and Savin-Williams (2011) maintained that curiosity frequently guides adolescents when experimenting sexually. Two different typologies of adolescents who use completely different contraceptive methods emerged from the health workers’ descriptions. The first type comprised adolescents who perceived themselves as omnipotent and invulnerable. According to the health workers, these adolescents had false beliefs regarding themselves and their health issues. In particular, omnipotent adolescents frequently did not use efficient contraceptive methods and avoided protecting themselves from the negative consequences of risky sexual behavior. Several authors found a connection between the adolescent’s belief in being omnipotent and invulnerable and higher risks of precocious pregnancy (Durant & Sanders, 1989) and contracting HIV (Cicognani & Zani, 1999), as well as the presence of several sexual partners (Greene, Rubin, Hale, & Walters, 1996; Serovich & Greene, 1997). In addition to omnipotent adolescents, health workers identified a completely different category of young patients. These girls worried about their health and came to the family health center looking for contraceptive counseling. These adolescents showed an awareness of the risks connected to sexual behavior and were conscious about the possible negative consequences of unsafe sexual behavior. Finally, the health workers underlined the importance of the emerging dimension of negotiation regarding contraceptive methods within the adolescent couple. According to the health workers, young couples discussed and communicated about contraception. Focusing on contraceptive negotiations, the researchers underlined the relationship between discussing this topic and the probability of using contraceptives (Kirby et al., 2007; Manlove, Ryan, & Franzetta, 2004). Finally, we included and interviewed health workers from different disciplines who met and interacted with these young patients at different moments and for different reasons. From our study, however, it emerged that in their practice with adolescents, all of them addressed their work by sharing
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the same representation of taking care, which takes place at three different levels. The first one is linked to a need for revising the information possessed by adolescents, correcting the wrong ideas, and putting them in order. In their experience, adolescents were not completely uninformed on sexual topics, but their knowledge needed supervision and improvement. Above all, they felt that adolescents mainly asked their peer group for advice and searched for help on the Internet, thus taking the chance of not finding adequate answers to their questions. The health workers are led by this concern in their practice: teenagers were perceived as badly equipped to safely deal with this developmental challenge. The health workers’ desires were therefore to put the adolescents’ information in order, dispel the false myths circulating among the youngest, correct the incorrect information, and teach the correct information. These concerns are supported by the findings of the Societ`a Italiana di Pediatria report (2012) highlighting that more than half of the interviewed adolescents believed in having all useful information about sexuality and contraceptive methods, and that their chosen information sources are friends and schoolmates. Second, the health workers expressed their desire to build a stable and lasting relationship with their young patients, starting from contraceptive counseling. The health workers hoped that adolescents looking for advice regarding contraception would have a long-term relationship with health workers, in the hopes of becoming a reference point for adolescents, so that they could ask for help in different times of their lives. The importance of creating a stable relationship with adolescents has already been highlighted in the literature. In their research focusing on midwives’ work with adolescent mothers, Wahn and colleagues (2007) identified the creation of trusting and long-term relationships with adolescents as a priority to sustain and support adolescents across the difficult challenges linked to motherhood. Third, at a higher level, the health workers were willing to make adolescents aware and autonomous in their decision-making processes concerning sexuality in particular and health in general. This desire to lead adolescents to become the protagonists of their lifestyle choices is linked to an educational mission that sees its ultimate goal in passing on the tools and equipment necessary to meet life’s challenges in a healthy and safe way. In addition to the necessity of providing adolescents with correct and complete information regarding contraception and sexuality, there is, in fact, the need to increase and promote these skills (critical thinking, decision making, and problem solving) in adolescents that could act as protective factors in their future lives. Researchers investigating the characteristic that sexual education interventions should have in order to be efficient (Federazione Italiana di Sessuologia Scientifica, 2011; Kirby, 2001, 2002; Kirby et al., 2007) underline the importance of engaging adolescents through an active methodology, using activities like role-playing, written exercises, and group discussion. All of these techniques aim at stimulating a profound reflection regarding
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sexuality, and this aspect seems to be the final aim of Italian health workers in taking care of their young patients.
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CONCLUSION When considering the implications of the findings, it is important to underline that this study was carried out with a limited number of health workers from a limited geographic region in Italy. Our findings cannot be generalized, therefore, although they can contribute to an area in health worker practice that has not been deeply investigated in earlier research. Moreover, the health workers taking part in the research were voluntarily recruited, and they had varying degrees of experience in caring for adolescents. Despite the limitations of the study, the following findings are relevant for the care of adolescents. In our opinion, several important aspects of working with adolescents emerged from this study, and the most important appeared to be linked to the specific characteristics of taking care of adolescents regarding sexuality and contraception issues. From our interviews, strong concerns regarding adolescent misinformation on sexual topics emerged, which led the way in caring for adolescents. The health workers emphasized the desire to engage and build lasting relationships with their young patients, aiming to be a positive reference point in their lives. Moreover, they proposed sustaining adolescents in this phase of life by promoting an aware and conscious attitude toward sexuality and contraception. In this way, health workers focused their practice not only on preventing sexual risk taking but also on promoting skills that can lead adolescents to be main protagonists in the choices that affect their lives and to be autonomous in taking care of themselves. We believe that working on preventing sexual risk taking will contribute to reductions in sexually transmitted diseases, undesired pregnancies, and abortion requests, which are all stressful life events for most women, regardless of their age. Moreover, we believe that also focusing on the promotion of adolescents’ personal life skills will be very useful in later life stages; during the transition from adolescence to adulthood, these skills could in fact bring about a safer and more positive management of romantic and sexual relations. Adolescents who are able to recognize their emotions and those of others, answer them in a responsive way, make healthy decisions, and solve problems will become, with greater probability, responsible adults who will respect their romantic and sexual partners. We believe that a longterm effect of implementing these abilities could also include decreases in stalking and dating violence, which are becoming more frequent among adolescents (Connolly et al., 2010; Williams, Connolly, Pepler, Craig, & Laporte, 2008).
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We perceived these health workers as being prepared and able to identify the specificities and different needs of their young patients by trying to answer them in a careful way. In our opinion, Italian health workers are guided in their work by a sense of concern for these adolescents, who are not always perceived as mature enough to face sexuality, but also by a desire to support them in their growth process and allow them to become responsible and healthy adults. We believe that health workers should be aware of their perceptions regard these young patients, because the ways in which these patients are perceived could influence the care relationship. In future research, it could be interesting to identify the adolescents’ beliefs and attitudes toward sexuality and contraception, and compare them with those of the health workers. Moreover, it could be relevant to investigate adolescents’ needs or desires to be taken care of by adults or professionals on these topics.
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